Employers’ Perception and Practice of Workplace Violence Prevention at Healthcare Facilities Questionnaire: A Confirmatory Factor Analysis

Background Workplace violence prevention initiatives are undeniably lacking in healthcare facilities. The aim of this study was to validate a newly developed questionnaire and assess employers’ perceptions and practices towards workplace violence prevention at healthcare facilities. Methods A cross-sectional study was conducted from October 2021 to November 2021 by recruiting 333 employers at healthcare facilities in Kelantan, Malaysia. The original draft of the Malay version of the questionnaire comprised 62 items constructed under two domains (perception and practice). A confirmatory factor analysis was conducted to evaluate construct validity and internal consistency using R software. Results The final model for the perception and practice domain of the questionnaire consisted of 13 factors and 56 items. The factor loadings for all items were above 0.6. The fit indices used for confirmatory factor analysis in the final model were as follows: χ2 = 2092.6 (P < 0.001), standardised root mean squared residual (SRMR) = 0.053, root mean square error of approximation (RMSEA) = 0.042, comparative fit index (CFI) = 0.928 and Tucker Lewis index (TLI) = 0.920. The construct reliability for all factors was reliable, with Raykov’s rho coefficients above 0.70. Conclusion The newly developed questionnaire demonstrated excellent psychometric properties and adequate validity and reliability, confirming that this instrument is reliable and valuable for evaluating employers’ perceptions and practices towards workplace violence prevention at healthcare facilities.

physical injuries (13).The literature has emphasised that whenever violence occurs in the workplace, the quality of health services will be substandard and the health of HCWs will be compromised, further undermining community health.
Several rules and regulations, such as the Occupational Safety and Health Act (OSHA) 1994, Employment Act 1955, Industrial Relations Act 1967, Minor Offences Act 1955 and Penal Code (Act 574), protect Malaysian workers from WPV.These rules and regulations allow victims to lodge reports following WPV incidents.Nevertheless, most verbal abuses, such as ridicule, innuendo and humiliation, do not constitute crimes, even if the victim is likely to sustain injuries due to these abuses.Another setback is that these laws do not ensure the safety of HCWs.Recent advances have included improved policies, procedures and guidelines on WPV, such as general guidelines for the prevention of WPV by the Department of Occupational Safety and Health (DOSH) Malaysia (2).In addition, the Ministry of Health Malaysia has launched guidelines and training modules on WPV prevention specifically for HCWs (14,15).However, unfortunately, the prevalence of WPV against HCWs in Malaysia continues to increase despite the launch and implementation of guidelines and training modules in healthcare facilities to prevent WPV.
Progressive measures should be adopted immediately to overcome the issue of WPV in healthcare facilities.A new perspective on WPV should be sought, particularly regarding healthcare employers' perceptions and practices towards WPV prevention.This requires a valid instrument for the assessment of healthcare employers' perceptions and practices towards WPV prevention.A better understanding of WPV prevention can be achieved using this new instrument, as it would allow the development of the best strategies to improve current measures.However, the existing questionnaire used to assess WPV among workers relies on relatively outdated criteria based on the joint programme of the International Labour Office (ILO), World Health Organization (WHO),

Introduction
Working in healthcare sectors requires that healthcare workers (HCWs) be fully focused, committed and self-cautious.HCWs are exposed to violence in the workplace but they are still expected to provide the best healthcare services.Healthcare facilities are unavoidably prone to workplace violence (WPV), despite the availability of guidelines and training modules to prevent its occurrence.WPV occurs when workers are abused, threatened or attacked under conditions connected with their work, including their commutes to and from work, and are exposed threats to their health, safety or wellbeing, either explicitly or implicitly (1).
According to Martino and Musri (2), the recognised forms of WPV include physical injuries, verbal abuse, racial abuse, bullying and sexual harassment.WPV can be classified into four types according to different perpetrators: Type I (criminal intent), Type II (patient/ visitor), Type III (worker-on-worker) and Type IV (organisational) (3).In healthcare facilities, HCWs are most prone to Type II WPV (4).Around the globe, WPV in healthcare facilities is reportedly high and increasing (5,6), and a similar trend is evident in Malaysia, where the reported WPV incidence was 71.3% in a public hospital (7) and 24.8% in primary care and the community-based setting (8).Overall, 70% of HCWs in Malaysia experienced verbal abuse, 33% experienced physical abuse, 25% experienced bullying, and 4% experienced sexual harassment in the workplace (4).
WPV against HCWs directly disharmonises working conditions in healthcare facilities and indirectly compromises the health of HCWs.Health service quality is compromised after every incident of violence in the workplace, causing patients to receive poor health services.Among the consequences of WPV on HCWs were depression, post-traumatic stress disorder, truancy at work, a high turnover rate at the workplace, malpractice and provision of poor health services (9,10).According to da Silva et al. (11), WPV is a risk factor for depressive symptoms among HCWs who have experienced violence in the workplace.These workers exhibit excessive sleep behaviour and display tiredness and reduced concentration while on duty.Aside from affecting their mental health, WPV against HCWs is also a risk factor for cardiovascular disease (12) and a cause of many other adverse (15 items), iii) WPV reporting (4 items) and iv) managerial role (5 items).All questions were close-ended and rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).

Study Design and Participants
A cross-sectional study was conducted between October 2021 and November 2021 in Kota Bharu, Kelantan, Malaysia.The study involved five categories of healthcare workplaces: i) hospitals, ii) health clinics, iii) dental clinics, iv) district health offices and v) district dental offices.Healthcare facility employers who had worked at least 12 months in the current workplace, as well as representatives from any of the levels of director of the organisation, location supervisor or members of occupational safety and health committees (OSHCs) were invited to participate in the study.The estimated sample size was 333 participants.The number of participants required for each workplace category was determined using a stratified proportionate sampling formula.We gathered a list of total employers in each workplace category during the initial recruitment process and then conducted participant selection using simple random sampling.Participants who consented to participate were given an online questionnaire via email and an online messaging platform.
The current study defined the director of an organisation as an employer in charge of healthcare facilities and included hospital directors and medical officers.The location supervisor was defined as the employer in charge of the respective department in healthcare facilities and included the heads of department, senior assistant medical officers, environmental health officers and matrons.The OSHC in healthcare facilities referred to the committees consisting of safety and health officers, workers and representatives of the organisation that aimed to improve health and safety at work.

Statistical Analysis
Data analysis in this study was performed using R software for Windows version R-4.2.1 (2022-06-23).The characteristics of the participants were analysed using descriptive analysis.The mean and standard deviation (SD) were used to describe continuous variables, whereas frequency and percentage were used to describe categorical variables.into the Malay language or adapted for local use.The aim of this study was to validate the newly developed Malay version of the Perception and Practice of Workplace Violence Prevention (PPWVP) questionnaire by addressing construct validity and instrument reliability among employers at healthcare facilities.

Questionnaire Development
Prior to confirmatory factor analysis (CFA), the researchers conducted a comprehensive literature review and group discussions with a panel of experts in WPV and subsequently developed the first draft of a Malay version of the PPWVP questionnaire.The steps involved in this process of questionnaire development were: i) domain identification and verification, ii) definition of the domain and components, iii) item generation, iv) formatting of the questionnaire, v) content validation, vi) face validation and vii) exploratory factor analysis (EFA).Two domains were constructed: i) the perception and ii) the practice towards WPV prevention.Each domain initially had six components and a combined total of 100 items.Two items in the practice domain were eliminated during content validation for having an item content validation index (I-CVI) below 0.78, while the remaining 98 items were kept in face validation until EFA.
Data for the EFA study were collected in the Bachok district, Kelantan, Malaysia.The gathered data were subjected to EFA analysis separately for the perception and practice domains.The EFA revealed a factor loading above 0.60 and Cronbach's alpha above 0.71 for the perception domain and above 0.82 for the practice domain.The final draft of the Malay version of the PPWVP questionnaire comprised 62 items constructed under the domains of perception (35 items) and practice (27 items).The perception domain consisted of nine components: i) form of WPV (8 items), ii) causes of WPV (3 items), iii) impacts of WPV (3 items), iv) benefits of WPV prevention (6 items), v) barriers to WPV prevention (5 items), vi) highstrain job characteristics (3 items), vii) reaction to WPV (3 items), viii) WPV protection (2 items) and ix) WPV prevention encouragement (2 items).By contrast, the practice domain consisted of four factors: i) workplace safety (3 items), ii) implementation of WPV prevention

Characteristics of Participants
Upon sampling recruitment, 333 employers of healthcare facilities were selected for the confirmatory factor analysis.The participants were obtained from five categories of healthcare facilities: i) hospitals, ii) health clinics, iii) dental clinics, iv) district health offices and v) district dental offices.These five healthcare workplaces, despite their variety, generally shared similar administration management and processing workflows.
According to the workplace categories, twothirds of the participants were from hospitals, and only one participant (0.3%) was from a district dental office (Table 1).

Confirmatory Factor Analysis
A check of the multivariate normality of the data revealed that the data were not multivariately normal.Therefore, the robust maximum likelihood (MLR) estimation method was used in the analysis and resulted in a 13-factor structure.The CFA verified three models.Model 1 consisted of 13 factors and 62 items.All items in this model had a factor loading greater than 0.60, except for six items with low factor loadings (≤ 0.60).The six items were 'Prevention against violence in the workplace improves the achievements of staff' in Factor 2, 'Violence at workplace occurs due to patient or visitor failing to control their emotions or anger' in Factor 4, 'I provide unfair service to the staff' and 'I pay less attention to the feelings of subordinates' in Factor 12, and 'I enjoy working with my staff' and 'I give support to staff who experience workplace violence' in Factor 13 (Table 2).
Model 2 removed six underperforming items.The remaining 56 items associated with the existing 13 factors showed factor loadings of at least 0.60 and above (Table 2).However, the fit indices were inadequate.Therefore, the localised areas of misfit were examined using CFA was performed using lavaan version 0.6-11 and semTools version 0.5-6 of the R packages (18,19) to test the fit of the data in relation to the factor structure.Prior to CFA analysis, descriptive statistics for the PPWVP questionnaire were computed to measure the mean scores for every item, dimension and outcome.Assumption checking was then carried out to determine the estimator used for the analysis in this study.The scale's dimensionality was determined using standardised factor loadings and a value of > 0.60 was accepted (20)(21)(22)).An item with low factor loading was removed unless it was considered meaningful (23).The model's goodness of fit was examined based on fit indices.Three model fit categories (absolute fit, parsimonious fit and comparative fit), their respective fit indices and the recommended cut-off values were observed (24,25).
Assessments of model fit were carried out using the assessment item fit and model fit criteria of the standardised root mean squared residual (SRMR), root mean square error of approximation (RMSEA), comparative fit index (CFI), Tucker Lewis index (TLI) and Chi-square test (χ 2 ).The SRMR is an absolute measure of fit and is defined as the standardised difference between the observed and predicted correlations.By contrast, RMSEA is an absolute fit index because it assesses how far the initial proposed model deviates from a perfect model.The CFI and TLI are incremental fit indices that compare the fit of a hypothesised model with that of a baseline model.The model was considered fit when the P-value (χ 2 ) > 0.05, SRMR and RMSEA < 0.08, relative chi-square < 3.0, CFI and TLI > 0.90 (25)(26)(27).
The model revision was considered by removing a problematic item, changing item loading to other factors if justified on the theoretical background or combining factors if they were highly correlated.However, the absolute fit index of minimum discrepancy χ 2 could be ignored when the study's sample size was greater than 200, and relative χ 2 was preferable for use as a fit index (28).Finally, the reliability test was determined by Raykov's rho coefficient and a threshold equal to or greater than 0.7 was considered adequate for this study (27).

Discussion
This study evaluated a psychometrically robust instrument to assess the perception and practices of WPV prevention among employers of healthcare facilities and to ensure that the instrument is culturally acceptable for use in Malaysia.The instrument is a newly developed Malay language questionnaire comprising modification indices (MIs).This test was used to determine whether any modifications could be performed to improve the model.Overall, 17 suggested specifications had MIs > 3.84.
The best model was Model 3, which had the exact number of factors and items as Model 2 but applied modification indices.All 13 factors, comprising 56 items, showed satisfactory factor loadings greater than 0.60 (Table 2).Moreover, all the fit indices indicated adequate goodness of fit.
Table 3 shows the details of the fit indices for each model.Model 1 did not achieve the standard values for the two fit indices: CFI (0.855) and TLI (0.843).Upon removal of the six items mentioned above, Model 2 also failed to achieve standard values for two similar fit indices: CFI (0.874) and TLI (0.862).However, Model 3 showed excellent values for all fit indices, indicating that this model was the best construct for the newly developed PPWVP questionnaire.The CFA produced and verified three models.Model 1 showed six items (items 9, 22, 56, 57, 58 and 60) with unacceptable factor loadings and unsatisfactory fit indices values.Items with factor loadings of 0.6 and lower should be dropped from the model to improve the validity and reliability of the instrument, as these items do not contribute to measuring WPV prevention initiatives will only be effective with support from the top, middle and low levels of management in an organisation.The initiative should be disseminated and sufficiently publicised among directors of organisations, location supervisors and OSHC members in healthcare facilities.
This study has a few limitations.One was that data were collected using onlinebased questionnaires via email and an online messaging platform.Many benefits of online questionnaires have been highlighted, such as their flexibility, cost-effectiveness, accessibility to participants, fewer transfer errors and no requirement for direct contact or addressing safety concerns (a particular concern during the COVID-19 pandemic) (35).Nevertheless, online questionnaires have some limitations, including a lack of verbal and direct one-way communication with participants, which may cause them to be motivationally deprived or to experience difficulty understanding the study's intention.Further confounding factors specific to Malaysia were the stigma of being blamed and the punitive culture of the Malaysian healthcare environment.Thus, participants possibly did not appreciate particular questions, as they feared the blaming culture, even though confidentiality and anonymity were clearly stated in this study (36,37).Another unavoidable limitation was the low response rate among the directors of organisations, possibly due to COVID-19 management time constraints.

Conclusion
This study showed that the newly developed PPWVP questionnaire in Malay is valid, reliable and culturally acceptable.Both the perception and practice domains, together with their constructed items, were found appropriate for assessing employers' perceptions and practices of WPV prevention at healthcare facilities.Therefore, the questionnaire can be used as an instrument for further study in local healthcare facilities and workplace settings, with some amendments to suit the particular workplace and local context.

Table 2 .
Factor loadings of PPWVP questionnaire for three models (n = 333) (continued on next page)

Table 4 demonstrates
Raykov's rho coefficients for the three models.All factors in each model achieved Raykov's rho coefficient values equal to or greater than 0.7.In addition, the construct reliability for all factors in Model 3 was reliable, with Raykov's rho coefficient values ranging from 0.72 to 0.94.The path diagram of Model 3 is shown in Figure1.The path diagram shows a standardised factor loading for Model 3, ranging from 0.621 to 0.884, which is a cut-off value > 0.6.